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or failed to improve with high-dose steroids. It is also important to

assess eye movement for evidence of extraocular muscle entrapment

(and/or nerve injury). Most important, before considering surgical

intervention around the orbit, an ophthalmological evaluation to rule

out ocular and/or retinal injury is mandatory.

2. Assessment of Other Nerves

Other nerves should be assessed, including trigeminal nerve function in

all divisions and particularly facial nerve function, since not only

documentation but also the possibility of decompression or peripheral

repair need to be considered when indicated.

3. Le Fort Fractures

Le Fort fractures are generally evaluated by assessing movement of the

tooth-bearing maxillary bones relative to the cranium, making sure that

the teeth themselves are not moving separately from the bone. The

anterior maxillary arch is held and rocked relative to a second hand on

the forehead. If there is movement of the maxillary arch and maxillae

relative to the frontal bones, then a Le Fort fracture can be presumed.

The level of movement may be difficult to detect, but the CT scan will

sort that out.

4. CT Scan

Finally, the CT scan is the key to the diagnosis of midfacial fractures. In

general, axial CTs are best for visualizing vertical bone structures, and

coronal CTs are best for visualizing horizontal structures, though with

modern CT algorithms and high-resolution scanning, both can be easily

produced and should be utilized. The three-dimensional (3D) CT is

helpful for creating a gestalt for the surgeon, but it is less accurate than

the axial and coronal CTs from which it is created.

E. Considerations for Repair of Midfacial Trauma

Midfacial bones are repaired for two main reasons: to restore normal

function and to restore normal facial contour (cosmesis). Before making

the decision to proceed with repair, it is important that the patient (and/

or family) understands the risks and benefits of the surgery, as well as

the risks of not repairing the fractures.

1. Orbital Fractures

The main dysfunction for which orbital repair is performed is diplopia,

which is usually due to muscle entrapment of one of the extraocular

muscles, though it can occur as a result of significant globe malposition

as well. Globe malposition can also cause significant cosmetic

deformity.